Transition to federalism: Healthier Nepal

Although the past decade has witnessed a dramatic improvement in the health of Nepalis, including declines in infant and maternal mortality, reductions in chronic malnutrition, and an overall jump in life expectancy, significant health care service gaps persist.

In the most recent Demographic Health Survey — the gold standard for assessing health indicators around the world — Nepal demonstrated impressive gains, but much work remains to ensure all Nepalis have access to quality health services, especially in rural communities.

My concern for equitable and accessible health care is not prompted solely by a humanitarian impulse, but also by the sure knowledge that only healthy people, supported by an equitable and accessible health care system, can fully contribute to the political and economic life of this country. Federalism offers a chance to close healthcare gaps.

Inequities, both in terms of the quality of and access to, essential health care, particularly in rural and remote areas of the country, are two of the chief problems in improving public health outcomes. For example, although 62 percent of new mothers living in the Hill regions receive postnatal care within two days of giving birth, this was only true for 49 percent of those from the mountain region.

Local governments can eliminate inequities if they embrace this opportunity to adopt a more community-centric approach than was possible under centrally-managed services.

This means opening up to an array of potential partners, using public funds transparently and strategically and engaging local citizens to best target their needs.

In the United States, we also face tremendous challenges in serving large, rural communities outside of major population centers, among other problems.

With a highly decentralized and very outcome-oriented healthcare system, we found that state and local governments can find ways to get services to people but that there is no one size fits all solution.

As just one example of how states approach this problem, rural communities in Mississippi are partnering with technology firms to provide telemedicine solutions to patients who are not able to reach health centers.

In other areas, innovative approaches to reaching those who are uninsured resulted in micro-insurance that provided lower cost alternatives to rural individuals.

The United States, with its unique federal system, is just one prism through which Nepalis may want to view future approaches to improved healthcare for rural and other residents.

The United States and Nepal have enjoyed a warm and productive bilateral relationship over the past 70 years.

The US Government contributed to many successes in achieving improved public health in Nepal. Some methods piloted in here – such as distributing vitamin A supplements to improve the health of young children and the use of chlorhexidine gel to reduce infant deaths – have been adopted around the world, saving millions of lives.

But now our approach has to change along with Nepal’s as this country marches toward decentralization.

For instance, newly elected local and provincial officials will have a strong perspective about their communities’ needs.

Under Nepal’s September 2015 Constitution, locally-elected officials now have authority to make critical decisions on funding, policy and programming that can improve the health and livelihoods of their constituents. Decentralized planning and budgeting will therefore allow municipalities to identify the most pressing health needs in their communities, tailor health programs to meet these needs and increase the impact of money spent on health.

Continuing these approaches, and creating stronger partnerships with the private sector, civil society, and donors, could further improve outcomes. The government is not the only source of solutions for the healthcare issues facing Nepal.

On the eve of greater decentralization in Nepal, local communities must seize this rare opportunity to work with a new constellation of partners to innovate and create a health care future that is more equitable and efficient.

The responsibility for delivering the kind of public health outcomes Nepalis want and deserve now rests with local communities governing themselves for the first time in twenty years.

I urge them to use the process of the transition to federalism to deliver services to their communities – and by doing so, ensure a healthier and more prosperous future for all Nepalis.